Office-Based Strategies to Combat Antimicrobial Resistance

 

The goal is not simply to avoid antibiotics but to use them in a judicious manner. Here are 10 steps family physicians, practices, and leaders can take.

Fam Pract Manag. 2021 Nov-Dec;28(6):15-20.

Author disclosures: no relevant financial affiliations.

Writing an antibiotic prescription is a common task for family physicians. In ambulatory settings, approximately 20% of pediatric visits1 and 10% of adult visits2 result in an antibiotic prescription. While antibiotics can save lives, inappropriate or unnecessary use may exacerbate existing antibiotic resistance. According to the Centers for Disease Control and Prevention (CDC), nearly 3 million antibiotic-resistant infections and more than 35,000 consequent deaths happen each year in the United States.3

The CDC published its first Antibiotic Resistance Threats in the United States report in 2013, highlighting key bacterial and fungal threats and providing an action plan to combat their spread. Since then, awareness of antibiotic resistance has grown among health professionals, as well as the public. Antibiotic stewardship programs are now the norm in health care, though much of the focus remains on hospital-based interventions even though more than 60% of antibiotic expenses in the U.S. are incurred in outpatient settings.4

Family physicians are critical and well-positioned to lead the antibiotic stewardship movement for a few simple reasons. First, we write more antibiotic prescriptions than any other medical specialty — about one-fifth of all outpatient antibiotics prescribed each year.5 As the highest-volume prescribers of antibiotics, improving our prescribing habits would have significant health implications for our patients. Second, family physicians train and practice across multiple health care settings (e.g., ambulatory clinics, urgent care centers, nursing homes, and hospitals) in partnership with other specialty physicians. With such diverse roles and practice settings, family physicians are uniquely positioned to amplify the cultural change needed to curb antibiotic resistance. Finally, and perhaps most importantly, the relationship and trust between family physicians and their patients make the primary care visit an ideal venue to educate patients about antibiotic stewardship.

So how can we start improving antibiotic prescribing? This article offers a few suggestions for three key groups — individual family physicians, practices, and leaders.

KEY POINTS

  • While antibiotics can save lives, inappropriate or unnecessary use may exacerbate existing antibiotic resistance.

  • Family physicians are critical to antibiotic stewardship, in part because they write about one-fifth of all outpatient antibiotic prescriptions each year.

  • Family physicians can ensure appropriate use of antibiotics by leveraging clinical decision support applications, improving patient communication skills, offering delayed antibiotic prescriptions, and using standardized order sets, among other strategies.

ABOUT THE AUTHORS

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Dr. Antono is a medical instructor in the Department of Family Medicine and Community Health at Duke University School of Medicine. He was formerly with Georgetown University School of Medicine and was the Robert L. Phillips, Jr. Health Policy Fellow at the Robert Graham Center in Washington, D.C....

Dr. Mishori is a professor of family medicine at Georgetown University School of Medicine.

Author disclosures: no relevant financial affiliations.

References

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1. Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011;128(6):1053–1061....

2. Shapiro DJ, Hicks LA, Pavia AT, Hersh AL. Antibiotic prescribing for adults in ambulatory care in the USA, 2007–09. J Antimicrob Chemother. 2014;69(1):234–240.

3. Antibiotic Resistance Threats in the United States, 2019. Centers for Disease Control and Prevention. Accessed Sept. 21, 2021. https://www.cdc.gov/

4. Suda KJ, Hicks LA, Roberts RM, Hunkler RJ, Danziger LH. A national evaluation of antibiotic expenditures by healthcare setting in the United States, 2009. J Antimicrob Chemother. 2013;68(3):715–718.

5. King LM, Bartoces M, Fleming-Dutra KE, Roberts RM, Hicks LA. Changes in U.S. outpatient antibiotic prescriptions from 2011–2016. Clin Infect Dis. 2020;70(3):370–377.

6. Coenen S, Francis N, Kelly M, et al. Are patient views about antibiotics related to clinician perceptions, management, and outcome? A multi-country study in outpatients with acute cough. PLOS ONE. 2013;8(10):e76691.

7. Mangione-Smith R, McGlynn EA, Elliott MN, McDonald L, Franz CE, Kravitz RL. Parent expectations for antibiotics, physician-parent communication, and satisfaction. Arch Pediatr Adolesc Med. 2001;155(7):800–806.

8. Mangione-Smith R, Zhou C, Robinson JD, Taylor JA, Elliott MN, Heritage J. Communication practices and antibiotic use for acute respiratory tract infections in children. Ann Fam Med. 2015;13(3):221–227.

9. Cals JWL, Bock L de, Beckers P-JHW, et al. Enhanced communication skills and C-reactive protein point-of-care testing for respiratory tract Infection: 3.5-year follow-up of a cluster randomized trial. Ann Fam Med. 2013;11(2):157–164.

10. Worrall G, Kettle A, Graham W, Hutchinson J. Postdated versus usual delayed antibiotic prescriptions in primary care. Can Fam Physician. 2010;56(10):1032–1036.

11. Spurling GK, Del Mar CB, Dooley L, Foxlee R, Farley R. Delayed antibiotic prescriptions for respiratory infections. Cochrane Database Syst Rev. 2017;9(9):CD004417.

12. Rowe TA, Linder JA. Delayed antibiotic prescriptions in ambulatory care: reconsidering a problematic practice. JAMA. 2020;323(18):1779–1780.

13. Branche A, Neeser O, Mueller B, Schuetz P. Procalcitonin to guide antibiotic decision making: Curr Opin Infect Dis. 2019;32(2):130–135.

14. Chua KP, Fischer MA, Linder JA. Appropriateness of outpatient antibiotic prescribing among privately insured U.S. patients: ICD-10-CM based cross sectional study. BMJ. 2019;364:k5092.

15. Meeker D, Knight TK, Friedberg MW, et al. Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial. JAMA Intern Med. 2014;174(3):425–431.

16. Hallsworth M, Chadborn T, Sallis A, et al. Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial. Lancet. 2016;387(10029):1743–1752.

17. Meeker D, Linder JA, Fox CR, et al. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial. JAMA. 2016;315(6):562–570.

 
 

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